How should I approach the management of a patient with chronic rhinosi

Guideline-aligned answer with reasoning, red flags and references. Clinically reviewed by Dr Kola Tytler MBBS CertHE MBA MRCGP.

Management approach for chronic rhinosinusitis unresponsive to intranasal corticosteroids:

Ensure the patient is using intranasal corticosteroids correctly and consider a high-dose nasal corticosteroid course (equivalent to mometasone 400 micrograms daily) for 14–21 days, as this may provide symptom improvement in adults and children aged 12 years and over .
Advise nasal saline irrigation with isotonic saline to relieve congestion and nasal discharge, as it is safe and effective .
Address and manage any contributing factors such as smoking, asthma, allergic rhinitis, and avoid allergic triggers to improve symptoms .
Consider a short course (1–2 courses per year) of systemic corticosteroids in adults with partially controlled or uncontrolled disease, but only after specialist advice due to potential adverse effects .
Temporarily add a nasal decongestant to nasal corticosteroid treatment if the nose is very blocked, but avoid long-term use due to risk of rebound congestion .
Antibiotics are generally not recommended routinely for chronic rhinosinusitis; seek specialist advice before considering long-term antibiotics due to limited evidence of benefit and potential adverse effects .
If symptoms persist beyond 6–12 weeks despite these measures, or if there are complicating factors (e.g., nasal polyps, anatomical obstruction, immunocompromise, or significant impact on quality of life), refer to an ear, nose, and throat (ENT) specialist for further assessment and possible interventions such as endoscopic sinus surgery .

How should I approach the management of a patient with chronic rhinosinusitis who has not responded to intranasal corticosteroids?